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Preventive Services
As of October 1, 2016
Preventive Services Overview
The Patient Protection and Affordable Care Act (PPACA) requires non-grandfathered health plans to
cover specific in-network services as preventive, with no cost sharing for plan years beginning on or after
Sept. 23, 2010. There is no requirement for out-of-network coverage for these services, nor does PPACA
prohibit cost sharing on out-of-network services.
The requirements of the preventive care rule under PPACA:

Apply only to network providers

Apply to fully insured and self-funded health plans

Apply to non-grandfathered plans (grandfathered plans may voluntarily adopt the services)

Allow plans to apply medical management guidelines to frequency, method and place of
service when not explicitly stated in the rule

Allow plans to provide coverage for services in addition to the recommended preventive
services and impose cost-sharing requirements for those additional services

Include some services that may be preventive or diagnostic (when these services are
performed and billed as screening services, they will be paid as a preventive service)
The specific preventive services include:

Items or services rated A or B in the current recommendations of the US Preventive Services
Task Force (USPSTF)

Immunizations recommended by the Advisory Committee on Immunization Practices (ACIP)
of the Centers for Disease Control and Prevention (CDC)

Evidence-informed preventive care and screenings for infants, children and adolescents as
provided in the comprehensive guidelines supported by the Health Resources and Services
Administration (HRSA)

Evidence-informed preventive care and screenings for women as provided for in the
comprehensive guidelines supported by the HRSA
These specific services are subject to change as new recommendations and guidelines are issued.
Plans must comply with these updates by their first plan year on or after the date that is one year after the
new recommendation is issued. UMR will implement the required changes to our standard coding across
our book of business within one year of the effective date of the recommendation.
All preventive services are included in the statutory definition of essential benefits and are subject to the
prohibition on lifetime/annual dollar maximums on essential benefits.
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Preventive Services Overview
Services Mandated by PPACA
Type of Preventive Service
PPACA Requirements
Abdominal aortic aneurysm screening
Males age 65-75
Bacteriuria screening
Pregnant females
Chlamydia infection screening
All sexually active females age 24 or younger, or older
pregnant women who are at risk
Gonorrhea screening
All sexually active females
Hepatitis B virus infection screening
Pregnant females and Persons at High Risk
Hepatitis C virus infection screening
Males and females
HIV screening for adolescents and adults
Males and females
Rh incompatibility screening
Pregnant females
Syphilis screening
Males and females
Genetic Counseling and Evaluation for
BRCA Testing; and BRCA Lab Screening
Females
Diabetes screening
Males and females age 40 to 70 years
Rubella screening by history of vaccination
or by serology
Females
Mammography screening
Females ages 40 and above, one every 1-2 years
Pap smear, cervical cancer screening
Females, ages 21-65
Cholesterol screening (lipid disorders
screening)
Males and females, ages 20 and above
Colorectal cancer screening
Males and females, ages 50-75
Wellness exams
Males and females
Immunizations
Males and females, Age and gender appropriate
Newborn screening
 Hearing
 Hypothyroidism
 Phenylketonuria
 Sickle Cell
Ages 0-90 days
Osteoporosis screening
Females
Screening and behavior counseling,
interventions in primary care to reduce
alcohol misuse
Males and females
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Preventive Services Overview
Services Mandated by PPACA cont.
Type of Preventive Service
PPACA Requirements
Aspirin for prevention of cardiovascular
disease
Males, ages 45-79 and females, ages 55-79
Screening for high blood pressure
(Clinical and Ambulatory Measurement)
Males and females, age 18 and above
Chemoprevention of breast cancer
Females
Primary care intervention to promote breast Females
feeding
Prevention of dental caries in pre-school
children
Males and females
Screening for depression in adults and
major depressive disorder in children and
adolescents
Males and females
Behavioral counseling in primary care to
promote a healthy diet
Males and females
Screening for obesity in adults
Males and females
Screening for obesity in children and
adolescents
Males and females ages 6 and older
Behavioral counseling to prevent sexually
transmitted infections
Males and females
Counseling and interventions to prevent
Males and females
tobacco use and tobacco-caused disease in
adults and pregnant women counseling and
interventions (adults)
Counseling and Interventions to Prevent
Tobacco Use in Children and Adolescents
Males and females
Screening for visual impairment in children
under age 5
Children under age 5
Behavioral Counseling to Prevent Skin
Cancer
Males and females, age 10-24
Hearing tests (Bright Futures services)
Males and females ages 0-21, once per year
Developmental/autism screening
Males and females ages 0-2
Lead screening
Males and females, ages 0-21
TB testing
Males and females, ages 0-21
Dyslipidemia screening
Males and females, ages 24 months-21 years
Metabolic screening panel
Males and females, ages 0-90 days
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Preventive Services Overview
Services Mandated by PPACA cont.
Type of Preventive Service
PPACA Requirements
Anemia screening in children
Males and females, ages 0-21
Prevention of Falls in Community-Dwelling
Older Adults
Males and females, age 65 or older
Screening for Intimate Partner Violence
Females
Medications that reduce the risk of primary
breast cancer
Females at increased risk for breast cancer
Screening for Lung Cancer, with Low-Dose
Computed Tomography
Males and Females, age 55-80
Fluoride Application in Primary Care
Males and Females, age 0-6
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Preventive Services Overview
The following chart describes services that are mandated by the Act and UMR standard coding criteria.
UMR uses the UnitedHealthcare Coverage Determination Guideline as the basis for our preventive
services approach. To finalize our approach, we also consider system capabilities, customer preferences
and whether UMR considered the service preventive prior to PPACA.
In addition to the UMR standard coding criteria covering mandated services, UMR is recommending four
additional services be included as preventive – CT colonography, PSA screenings for men over 40,
colorectal cancer screening for all ages, screening mammography for all women regardless of age. Plans
may choose to implement UMR’s standard coding only or the recommended list with these four additional
services.
Services Mandated by PPACA (UMR Approach)
Mandated Preventive Service
UMR standard coding criteria
Abdominal aortic aneurysm screening
Ages 65-75
Bacteriuria screening
During Pregnancy
Chlamydia infection screening
Covered
(coded as preventive prior to PPACA, venipuncture covered
as preventive when billed with preventive diagnosis code)
Gonorrhea screening
Covered
(coded as preventive prior to PPACA)
Hepatitis B virus infection screening
During Pregnancy, and Persons at High Risk
(venipuncture covered as preventive when billed with
preventive diagnosis code)
Hepatitis C virus infection screening
Covered
(venipuncture covered as preventive when billed with
preventive diagnosis code)
HIV screening for adolescents and adults
Covered
(coded as preventive prior to PPACA, venipuncture covered
as preventive when billed with preventive diagnosis code)
Rh incompatibility screening
During Pregnancy
(coded as preventive when billed with preventive diagnosis
code)
Syphilis screening
Covered
(coded as preventive prior to PPACA, venipuncture covered
as preventive when billed with preventive diagnosis code)
Genetic Counseling and Evaluation for
BRCA Testing; and BRCA Lab Screening
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Covered
Preventive Services Overview
Services Mandated by PPACA (UMR Approach) Cont.
Mandated Preventive Service
UMR standard coding criteria
Diabetes screening
Covered
(coded as preventive prior to PPACA)
Rubella screening by history of vaccination
or by serology
Covered (venipuncture covered as preventive when billed
with preventive diagnosis code)
Mammography screening
Ages 40 and above, one every year
Pap smear, cervical cancer screening
Covered
Cholesterol screening (lipid disorders
screening)
Covered
(venipuncture covered as preventive when billed with
preventive diagnosis code)
Colorectal cancer screening
Ages 50-75
Wellness exams
Covered
Immunizations
Age and gender appropriate
Newborn screening
Ages 0-90 days
Osteoporosis screening
Covered
(coded as preventive prior to PPACA)
Screening and behavior counseling,
interventions in primary care to reduce
alcohol misuse
Covered
Aspirin for prevention of cardiovascular
disease
Covered
(typically included in preventive office visit)
Screening for high blood pressure
(Clinical and Ambulatory Measurement)
Covered
(typically included in preventive office visit)
Chemoprevention of breast cancer
Covered
(coded as preventive prior to PPACA)
Primary care intervention to promote breast Covered
feeding
(typically included in preventive office visit)
Prevention of dental caries in pre-school
children
Covered
Screening for depression in adults and
major depressive disorder in children and
adolescents
Covered
Behavioral counseling in primary care to
promote a healthy diet
Covered
Screening for obesity in adults
Screening for obesity in children and
adolescents
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Covered
Ages 6 and older
Preventive Services Overview
Services Mandated by PPACA (UMR Approach) Cont.
Mandated Preventive Service
UMR standard coding criteria
Behavioral counseling to prevent sexually
transmitted infections
Covered
Counseling and interventions to prevent
tobacco use and tobacco-caused disease in
adults and pregnant women counseling and
interventions (adults)
Covered
Effective plan years on or after 1/1/15 interventions include
prescription and over the counter tobacco cessation
products.
Counseling and Interventions to Prevent
Tobacco Use in Children and Adolescents
Covered
Screening for visual impairment in children
under age 5
Covered
(typically included in preventive office visit)
Behavioral Counseling to Prevent Skin
Cancer
Males and females, age 10-24
Hearing tests (Bright Futures services)
Ages 0-21, once per year
Developmental/autism screening
Ages 0-2 (ends on 3rd birthday)
Lead screening
Ages 0-21
(venipuncture covered as preventive when billed with
preventive diagnosis code)
TB testing
Ages 0-21
Dyslipidemia screening
Ages 0-21
(venipuncture covered as preventive when billed with
preventive diagnosis code
Metabolic screening panel
Ages 0-90 days
(venipuncture covered as preventive when billed with
preventive diagnosis code
Anemia screening in children
Ages 0-21
(venipuncture covered as preventive when billed with
preventive diagnosis code)
Prevention of Falls in Community-Dwelling
Older Adults
Ages 65 or older
(typically included in preventive office visit)
Screening for Intimate Partner Violence
Covered
(typically included in preventive office visit)
Medications that reduce the risk of primary
breast cancer
Ages 35 or older, that meet clinical criteria
Screening for Lung Cancer, with Low-Dose
Computed Tomography
Ages 55-80, once per year
Fluoride Application in Primary Care
Ages 0-6
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Preventive Services Overview
Women’s Preventive Health Services
Expanded health plan coverage guidelines
Under the Affordable Care Act (ACA), women’s preventive health care, such as mammograms, cervical
cancer screenings and prenatal care, is covered with no cost sharing for new health plans. The
Department of Health and Human Services (HHS) introduced expanded coverage for women’s preventive
services on Aug. 1, 2011.
Non-grandfathered plans and issuers were required to provide coverage without cost sharing consistent
with these expanded guidelines in the first plan year that began on or after Aug. 1, 2012.
The requirements for women’s expanded preventive health services are the same as the current
preventive care rule under PPACA.
PPACA expanded services for women compared to Sept. 23, 2010 preventive implementation
Type of Preventive Service
Well-woman examinations*
PPACA Requirements
Annually
Some lab services explicitly required
in HHS rules
Tobacco cessation counseling specific
to pregnant women
Well-woman examinations
(prenatal)
Expanded Women’s Preventive
As many as necessary to obtain
specified preventive services
As many as necessary to obtain
specified preventive services,
including:
 Routine prenatal obstetrical office
visits/low risk, uncomplicated
pregnancies
 All lab services explicitly required
in HHS rules
 Tobacco cessation counseling
specific to pregnant women
 Immunizations, especially
directed to pregnant women
Excludes:
 Radiology services not specified
in HHS requirements
 Delivery
 High-risk prenatal services
Screening for gestational
diabetes*
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Pregnant women at risk
All pregnant women (24-28 weeks);
high-risk women screened twice
Preventive Services Overview
Type of Preventive Service
PPACA Requirements
Human papillomavirus (HPV)
DNA testing
Women at risk
Counseling for sexually
transmitted infections*
Women at risk (teenaged, pregnancy,
lifestyle)
Expanded Women’s Preventive
All women age 30 and older, every
three years
All sexually active women
Counseling and screening for
human immune-deficiency (HIV) Women at risk (pregnancy, lifestyle)
virus*
All sexually active women
Counseling for and payment of
FDA-approved contraceptive
methods, including
sterilizations
Not applicable
All methods, all women
Note: Contact prescription benefits
manager
Breastfeeding support,
supplies, and counseling
Coverage for counseling only
Part of pre/post-natal counseling,
coverage for rental of breast-feeding
equipment
Screening and counseling for
domestic violence
Women at risk
All women
* UMR considered these services preventive prior to health care reform and, if applicable, payable to both
women and men.
FDA-approved contraception methods requiring first-dollar coverage:

Contraceptive medications (including sterilization)

Barrier methods (diaphragms)

Hormonal methods

Emergency contraception
Customers should work with their prescription benefits manager to determine reasonable medical
management techniques, such as tiers, exclusions, ancillary charges, notification and step therapy to
control costs and promote delivery of care.
Religious exemption and Eligible Organization
Contraceptive coverage final rules released on June 28, 2013 simplified the Religious Employer
Exemption (REE) requirements for plan years beginning on or after Aug. 1, 2013. The REE definition is
simplified to mean a non-profit religious employer under Internal Revenue Code. Religious Employer
refers to churches, other houses of worship, their integrated auxiliaries and conventions or association of
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Preventive Services Overview
churches, as well as the exclusively religious activities of any religious order. These plans can continue to
exclude coverage for contraceptives.
An Eligible Organization is a non-profit religious organization with religious objections to covering
contraceptive services. On Jul. 14, 2015, final rules were released that expanded the Eligible
Organization accommodation to closely held for-profit entities with religious objections. Those
organizations that self-certify as an Eligible Organization may exclude coverage for some or all
contraceptive services. A self-certification form (EBSA Form 700) from the Department of Labor must be
completed by employers claiming the Eligible Organization. EBSA 700 forms should be submitted to your
Strategic Account Executive. An Eligible Organization may use the alternate process to notify HHS of its
objection. HHS will then notify the Eligible Organization’s insurers or TPAs.
UMR Approach (and variations on guidelines)
Type of Preventive Service
UMR standard coding criteria
Available Comments/Variations
Well-woman examinations
Comment: Considered preventive
As many as necessary to obtain specified prior to health care reform and
preventive services
currently covered under preventive
benefits (refer to the UMR Standard
coding criteria in Preventive table
above).
Well-woman examinations
(prenatal)
As many as necessary to obtain specified Comment: Global maternity claims
preventive services, including:
will be paid based on a percentage
 Routine prenatal obstetrical office split:
visits/low risk, uncomplicated
pregnancies
 Routine prenatal visits
 All lab services explicitly required
represent 44% of eligible
in HHS rules
expenses and must be
 Tobacco cessation counseling
covered under the preventive
during pregnancy
care benefit
 Immunizations, especially
directed during pregnancy
 The remaining 56% of eligible
Excludes:
expenses will be covered
 Radiology services not specified in
under the medical benefit
HHS requirements
 Delivery
 High-risk prenatal services
Diabetes screening procedure covered
when billed with:


Screening for diabetes

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Pregnancy ICD-9 code OR
Hypertension ICD-9 diagnosis
code
OR
 Diabetes screening ICD-9
diagnosis code
Comment: Considered preventive
prior to health care reform and
currently covered under preventive
benefits (refer to the UMR Standard
coding criteria in Preventive table
above).
Preventive Services Overview
UMR Approach (and variations on guidelines)cont.
Type of Preventive Service
Human papillomavirus (HPV)
DNA testing
UMR standard coding criteria
Available Comments/Variations
Variation: Age (remove age
restriction)
Ages 30 and older
Variation: Frequency (1 every 3
years)
Covered
Comment: Considered preventive
prior to health care reform and
currently covered under preventive
benefits (refer to the UMR Standard
coding criteria in Preventive table
above).
Counseling and screening for
human immune-deficiency
Covered
(HIV) virus
Comment: Considered preventive
prior to health care reform and
currently covered under preventive
benefits (refer to the UMR Standard
coding criteria in Preventive table
above).
Counseling for sexually
transmitted infections
Counseling for and payment
of FDA-approved
contraceptive methods,
including sterilizations
All methods
Breastfeeding support,
supplies, and counseling
Part of pre/post-natal counseling,
coverage for purchase of an electric
breast pump and the rental up to the full
purchase price of a hospital grade pump
when received through a DME provider.
One per delivery.
Variation: Cover vasectomy
Screening and counseling for
Covered
domestic violence
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Comment: Contact prescription
benefits manager
Variation: Employers can choose to
cover purchases of breast pumps at a
retail store (i.e. Target) and members
submit receipts for reimbursement.
Comment: Considered preventive
prior to health care reform and
currently covered under preventive
benefits (refer to the UMR Standard
coding criteria in Preventive table
above).